Question 1

What are the main components of a respiratory assessment?

Accepted Answer

A respiratory assessment includes subjective and objective data. Subjective assessment involves interviewing the patient about medical history, respiratory symptoms, medications, and lifestyle factors. Objective assessment includes checking vital signs, respiratory rate, and pulse oximetry, then performing inspection, palpation, percussion, and auscultation of the chest to evaluate respiratory health comprehensively.

Question 2

What abnormal breath sounds should nurses listen for during auscultation?

Accepted Answer

During auscultation with a stethoscope, nurses listen for adventitious lung sounds that indicate abnormalities. These include wheezes, crackles, rales, rhonchi, stridor, and pleural rub. Normal breath sounds include bronchial sounds over the trachea, bronchovesicular sounds over major bronchi, and vesicular sounds over lung surfaces. Abnormal sounds may suggest airway obstruction or infection.

Question 3

How do nurses assess chest expansion during palpation?

Accepted Answer

Nurses place their hands on the chest at the same level and observe for symmetric expansion during breathing. Unequal expansion may indicate conditions like pneumonia or pneumothorax. Palpation also helps investigate abnormalities related to injury or procedural complications. The chest wall is assessed for tenderness and abnormal expansion patterns.

Question 4

What do percussion sounds reveal about lung tissue?

Accepted Answer

Percussion involves striking fingers over lung fields to differentiate sounds. Dull sounds indicate high-density areas such as pneumonia or atelectasis. Clear, low-pitched, hollow sounds are typical of normal lung tissue. These percussion findings help nurses identify potential respiratory consolidations or fluid accumulation in the pleural space.

Question 5

What vital sign values indicate normal respiratory function?

Accepted Answer

Adults typically have a respiratory rate of 12-20 breaths per minute at rest. Ideal blood oxygen saturation levels (SpO2) range between 95-100 percent. Assessment begins by interpreting these vital signs along with pulse oximetry readings. These baseline values help nurses identify respiratory distress or compromised oxygen delivery.

Question 6

What visual signs during inspection suggest respiratory compromise?

Accepted Answer

Inspection focuses on breathing patterns and signs of respiratory difficulty. Nurses observe for pursed-lip breathing, nasal flaring, and intercostal retractions. Cyanosis around the lips or nail beds may suggest low oxygen levels. Asymmetric chest expansion or abnormal chest configuration also indicates potential respiratory problems requiring further investigation.

Question 7

What subjective information should nurses gather about respiratory history?

Accepted Answer

Nurses should ask about past respiratory conditions like asthma, chronic bronchitis, or emphysema, plus surgeries and allergies. Family history helps identify genetic predispositions. Nurses inquire about cough presence, frequency, severity, and factors that worsen or alleviate symptoms. Information on sputum color, consistency, and amount provides insights into potential respiratory conditions.

Valutazione Respiratoria II

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